Evaluating newly approved drugs in combination regimens for multidrug-resistant tuberculosis with fluoroquinolone resistance (endTB-Q): study protocol for a multi-country randomized controlled trial

BACKGROUND

Treatment for fluoroquinolone-resistant multidrug-resistant/rifampicin-resistant tuberculosis (pre-XDR TB) often lasts longer than treatment for less resistant strains, yields worse efficacy results, and causes substantial toxicity. The newer anti-tuberculosis drugs, bedaquiline and delamanid, and repurposed drugs clofazimine and linezolid, show great promise for combination in shorter, less-toxic, and effective regimens. To date, there has been no randomized, internally and concurrently controlled trial of a shorter, all-oral regimen comprising these newer and repurposed drugs sufficiently powered to produce results for pre-XDR TB patients.

METHODS

endTB-Q is a phase III, multi-country, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of a treatment strategy for patients with pre-XDR TB. Study participants are randomized 2:1 to experimental or control arms, respectively. The experimental arm contains bedaquiline, linezolid, clofazimine, and delamanid. The control comprises the contemporaneous WHO standard of care for pre-XDR TB. Experimental arm duration is determined by a composite of smear microscopy and chest radiographic imaging at baseline and re-evaluated at 6 months using sputum culture results: participants with less extensive disease receive 6 months and participants with more extensive disease receive 9 months of treatment. Randomization is stratified by country and by participant extent-of-TB-disease phenotype defined according to screening/baseline characteristics. Study participation lasts up to 104 weeks post randomization. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 324 participants across 2 arms affords at least 80% power to show the non-inferiority, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per-protocol populations.

DISCUSSION

This internally controlled study of shortened treatment for pre-XDR TB will provide urgently needed data and evidence for clinical and policy decision-making around the treatment of pre-XDR TB with a four-drug, all-oral, shortened regimen.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03896685. Registered on 1 April 2018; the record was last updated for study protocol version 4.3 on 17 March 2023.

Microstructure-Thermal Property Relationships of Poly (Ethylene Glycol-b-Caprolactone) Copolymers and Their Micelles

The crystallinity of polymers strongly affects their properties. For block copolymers, whereby two crystallisable blocks are covalently tethered to one another, the molecular weight of the individual blocks and their relative weight fraction are important structural parameters that control their crystallisation. In the case of block copolymer micelles, these parameters can influence the crystallinity of the core, which has implications for drug encapsulation and release. Therefore, in this study, we aimed to determine how the microstructure of poly(ethylene glycol-b-caprolactone) (PEG-b-PCL) copolymers contributes to the crystallinity of their hydrophobic PCL micelle cores. Using a library of PEG-b-PCL copolymers with PEG number-average molecular weight (Mn) values of 2, 5, and 10 kDa and weight fractions of PCL (fPCL) ranging from 0.11 to 0.67, the thermal behaviour and morphology were studied in blends, bulk, and micelles using differential scanning calorimetry (DSC), wide-angle X-ray diffraction (WXRD), and Synchrotron wide-angle X-ray scattering (WAXS). Compared to PEG and PCL homopolymers, the block copolymers displayed reduced crystallinity in the bulk phase and the individual blocks had a large influence on the crystallisation of one another. The fPCL was determined to be the dominant contributor to the extent and order of crystallisation of the two blocks. When fPCL < 0.35, the initial crystallisation of PEG led to an amorphous PCL phase. At fPCL values between 0.35 and 0.65, PEG crystallisation was followed by PCL crystallisation, whereas this behaviour was reversed when fPCL > 0.65. For lyophilised PEG-b-PCL micelles, the crystallinity of the core increased with increasing fPCL, although the core was predominately amorphous for micelles with fPCL < 0.35. These findings contribute to understanding the relationships between copolymer microstructure and micelle core crystallinity that are important for the design and performance of micellar drug delivery systems, and the broader application of polymer micelles.

355 Comparison of Outcomes in Surgical and Endoscopic Transgastric Cystgastrostomy for Severe Acute Pancreatitis

Aim

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. A select group of patients may be suitable for surgical (S-CG), which can be performed open or laparoscopic, or endoscopic (E-CG) transgastric cystgastrostomy (TCG) of symptomatic or infected retrogastric pancreatic collections (walled-off pancreatic necrosis (WOPN) or pseudocyst). There is limited data comparing outcomes between these approaches.

Method

Retrospective analysis of all patients that underwent S-CG or E-CG was performed from a single, high-volume benign pancreatic centre between 2012 – 2021 inclusive. Patient demographics, clinical characteristics, and outcomes of these 3 groups was compared. One-way analysis of variance tests was used to compare categorical data.

Results

47 patients underwent TCG: 20 S-CG (12 open and 8 laparoscopic), and 27 E-CG. There was no statistical difference between S-CG and E-CG for age, body mass index (BMI), aetiology, organ failure and type or position of collection. S-CG patients had less burden of pre-existing co-morbidities (APACHE-II and Charlson-Co-morbidity-Index (CCI)) (p&lt;0.05). S-CG patients had shorter length of stay, emergency readmission and reintervention (p&lt;0.05). Those who underwent E-CG had higher burden of intervention due to persistent/recurrent pancreatic collections, with 33% mortality rate (p &lt;0.05).

Conclusions

S-CG, in a select group of patients, provides a single-staged intervention for drainage of transgastric pancreatic collections, especially when they predominantly contain solid necrosis and patient is suitable for general anaesthetic. Outcomes are favourable for S-CG, but multidisciplinary approach is critical to delineate the most appropriate approach for each individual patient.

Early weight gain trajectories in first episode anorexia: predictors of outcome for emerging adults in outpatient treatment

BACKGROUND

Early response to treatment has been shown to be a predictor of later clinical outcomes in eating disorders (EDs). Specifically, early weight gain trajectories in anorexia nervosa (AN) have been shown to predict higher rates of later remission in inpatient treatment. However, no study has, as of yet, examined this phenomenon within outpatient treatment of first episode cases of AN or in emerging adults.

METHODS

One hundred seven patients with AN, all between the ages of 16 and 25 and with an illness duration of < 3 years, received treatment via the first episode rapid early intervention in eating disorders (FREED) service pathway. Weight was recorded routinely across early treatment sessions and recovery outcomes (BMI > 18.5 kg/m2 and eating psychopathology) were assessed up to 1 year later. Early weight gain across the first 12 treatment sessions was investigated using latent growth mixture modelling to determine distinct classes of change. Follow-up clinical outcomes and remission rates were compared between classes, and individual and clinical characteristics at baseline (treatment start) were tested as potential predictors.

RESULTS

Four classes of early treatment trajectory were identified. Three of these classes (n = 95), though differing in their early change trajectories, showed substantial improvement in clinical outcomes at final follow-up. One smaller class (n = 12), characterised by a 'higher' start BMI (> 17) and no early weight gain, showed negligible improvement 1 year later. Of the three treatment responding groups, levels of purging, depression, and patient reported carer expressed emotion (in the form of high expectations and low tolerance of the patient) determined class membership, although these findings were not significant after correcting for multiple testing. A higher BMI at treatment start was not sufficient to predict optimal clinical outcomes.

CONCLUSION

First episode cases of AN treated via FREED fit into four distinct early response trajectory classes. These may represent subtypes of first episode AN patients. Three of these four trajectories included patients with substantial improvements 1 year later. For those in the non-response trajectory class, treatment adjustments or augmentations could be considered earlier, i.e., at treatment session 12.

699 Pre-Operative Screening and Investigation of Patients with Suspected Non-Alcoholic Fatty Liver Disease Among Bariatric Surgery Patients

Introduction

Non-alcoholic fatty liver disease (NAFLD) is becoming more prevalent. The investigations used to diagnose NAFLD include FIB-4 score, NAFLD score and AST/ALT ratio (AAR). Gold-standard for diagnosis is liver biopsy. Bariatric surgery reduces steatosis and fibrosis in NAFLD patients. However, in undiagnosed NAFLD, it can lead to worsening fibrosis and decompensation of cirrhosis, causing complications.

The aim is to identify how well bariatric patients are being screened for NAFLD pre-operatively.

Method

Database analysis was conducted in the bariatric clinics at Royal Derby Hospital and analysed using SPSS.

Results

392 patients’ data (Overall group) were analysed and compared with those who had an AAR&gt;1 (Abnormal group). Abnormal group had a higher mean AAR, NAFLD and FIB-4 scores. Surprisingly, ALT and AST levels were higher in Overall group compared to Abnormal. Generally, patients were not pre-operatively checked sufficiently (81.9% LFTs, 62.2% ASTs).

Conclusions

A large number of patients could have undiagnosed NAFLD due to the lack of LFT/AST checks as ALT scores alone would miss fibrosis. Using AAR&gt;1 and FIB-4 would allow clinicians to detect fibrosis earlier to carry out non-invasive diagnostic measures, avoiding unnecessary biopsies. Early diagnosis means patients undergoing bariatric surgery with possible cirrhosis will not experience decompensation and associated complications.

Comparing trends of perinatal mortality in two rural areas of Matlab, Bangladesh

The study conducted in a rural sub-district, Matlab, Bangladesh among adolescent motherhood (10-19 years) in the International Centre for Diarrhoeal Disease Research, Bangladesh included total of 4,996 adolescent mothers in the analysis. Chi-square tests and binary logistic regression were used to document adolescent pregnancy trends and the differences in and causes of perinatal death. The fertility rate was 27 per 1000 adolescent mothers in ISA and 20 per 1000 adolescent mothers in GSA, during the 9 year of study period. The adjusted odds of an adolescent mother having a perinatal death in ISA, relative to GSA was 0.69 (95% CI: 0.52 - 0.91, p-value&lt;0.05). Significant determinants of perinatal death among adolescent mothers were: maternal education, paternal education, mothers' age at first birth, asset score and distance from nearest facility. Dr. Rahman will raise the importance of addressing these determinants in designing health policy interventions targeting this specifically vulnerable group.

Ankylosis of a knee joint from Medieval London: Trauma, congenital anomaly or osteoarthritis?

OBJECTIVE

To explore the differential diagnoses of a fused left knee joint and the subsequent impairment.

MATERIALS

An adult female skeleton from the Medieval cemetery of St Mary Spital (London, England).

METHODS

We employed digital radiography and macroscopic observation to record the changes observed throughout the skeleton. We also used the Index of Care to explore the subsequent impairment.

RESULTS

A range of congenital and developmental conditions were identified throughout the axial skeleton, with changes to the spine, pelvis, arms and leg bones reflecting adaptation to the mobility impairment.

CONCLUSIONS

In all probability, the left knee reflects a case of congenital ankylosis with a differential diagnosis of subadult trauma. The female's skeleton had adapted to the impairment. Their risk is likely to have been elevated because of climatic and pandemic events during this period.

SIGNIFICANCE

First reported case of congenital knee ankylosis.

LIMITATIONS

The left knee joint was damaged during excavation.

SUGGESTIONS FOR FURTHER RESEARCH

Additional imaging is advised.

Novel use of Cytosorb™ haemadsorption to provide biochemical control in liver impairment

We describe the use of Cytosorb™, a synthetic extracorporeal haemoperfusion adsorption column, in the management of two patients with drug induced cholestasis and a third with alcoholic hepatitis and subsequent acute on chronic liver failure. Cytosorb was used in these patients to remove bilirubin and bile acids by supporting impaired excretory hepatic function, alleviating symptoms with the intention of serving as a bridge to endogenous recovery. The first two cases demonstrate favourable biochemical and symptomatic responses; the third case demonstrated a good biochemical response but subsequently died from the complications of multiple organ failure. These cases suggest Cytosorb™ be evaluated as an adjunct to support liver excretory functions in other arenas, such as acute liver failure or overdose. It remains unclear whether extracorporeal therapies removing liver toxins allow faster or more complete spontaneous recovery of endogenous function.

Review article: 2014 UK consensus guidelines - hepatitis C management and direct-acting anti-viral therapy

BACKGROUND

Therapeutic options for the management of hepatitis C virus (HCV) infection have evolved rapidly over the past two decades, with a consequent improvement in cure rates. Novel therapeutic agents are an area of great interest in the research community, with a number of these agents showing promise in the clinical setting.

AIMS

To assess and present the available evidence for the use of novel therapeutic agents for the treatment of HCV, updating previous guidelines.

METHODS

All Phase 2 and 3 studies, as well as abstract presentations from international Hepatology meetings were identified and reviewed for suitable inclusion, based on studies of new therapies in HCV. Treatment-naïve and experienced individuals, as well as cirrhotic and co-infected individuals were included.

RESULTS

Sofosbuvir, simeprevir and faldaprevir, along with pegylated interferon and ribavirin, have a role in the treatment of chronic HCV infection. The precise regimens are largely dependent on the patient characteristics, patient and physician preferences, and cost implication.

CONCLUSIONS

Therapies for chronic HCV have evolved dramatically in recent years. Interferon-free regimens are now possible without compromise in the rate of sustained viral response. The decision as to which regimen is most appropriate is multifactorial, and based on efficacy, safety and cost.

Service provision for liver disease in the UK: a national questionnaire-based survey

The National Plan for Liver Services in 2009 called for a review of current liver services across the UK to identify areas of good and poor provision. We present the results of a national questionnaire survey of liver services, which focussed on staffing and training, access to key facilities and clinical management of liver disease. Areas of good practice include the increased proportion of consultants who trained at a liver centre, the introduction of specific liver clinics and the widespread use of terlipressin and antibiotics for variceal bleeding. Areas of poor practice include limited access to alcohol psychiatry services and transjugular intrahepatic portosystemic shunts (TIPS) and limited recording of outcome measures or patient databases. Wide variation in the clinical management of serious liver diseases supports the need for managed clinical networks. These results will help to guide the development of standards of care for liver services across the UK.

UK consensus guidelines for the use of the protease inhibitors boceprevir and telaprevir in genotype 1 chronic hepatitis C infected patients

BACKGROUND

The nonstructural 3 serine protease inhibitors (PIs), boceprevir and telaprevir, represent the first in a new generation of directly acting antivirals against genotype 1 hepatitis C (HCV) infection. When used in combination with pegylated interferon and ribavirin, these drugs greatly improve sustained virological response rates in both treatment-naïve patients and patients who have had previous virological failure on treatment. However, the addition of these new agents will increase the complexity of therapeutic regimens, the rates of side-effects and costs.

AIMS

To review concisely the current evidence and to suggest current best practice, for the use of telaprevir and boceprevir in the management of chronic genotype 1 HCV infection.

METHODS

These guidelines for the use of boceprevir and telaprevir have been formulated following extensive review of the current literature, are based on the consensus opinion of a panel of national experts, and have been openly discussed and debated at a national meeting of HCV care providers.

RESULTS

We have made recommendations on a number of the key practical issues facing HCV care providers: (i) Which patients to treat?; (ii) Standards for the provision of care; (iii) Pre-treatment considerations; (iv) Which treatment regimens to use?; (v) Stopping rules; and (vi) Management of adverse effects. Finally, we have produced suggested algorithms for the assessment and treatment of these patients.

CONCLUSIONS

These UK Consensus guidelines indicate the current best practice for the use of boceprevir and telaprevir in the management of genotype 1 chronic HCV infection.

UK consensus guidelines for the use of the protease inhibitors boceprevir and telaprevir in genotype 1 chronic hepatitis C infected patients

BACKGROUND

The nonstructural 3 serine protease inhibitors (PIs), boceprevir and telaprevir, represent the first in a new generation of directly acting antivirals against genotype 1 hepatitis C (HCV) infection. When used in combination with pegylated interferon and ribavirin, these drugs greatly improve sustained virological response rates in both treatment-naïve patients and patients who have had previous virological failure on treatment. However, the addition of these new agents will increase the complexity of therapeutic regimens, the rates of side-effects and costs.

AIMS

To review concisely the current evidence and to suggest current best practice, for the use of telaprevir and boceprevir in the management of chronic genotype 1 HCV infection.

METHODS

These guidelines for the use of boceprevir and telaprevir have been formulated following extensive review of the current literature, are based on the consensus opinion of a panel of national experts, and have been openly discussed and debated at a national meeting of HCV care providers.

RESULTS

We have made recommendations on a number of the key practical issues facing HCV care providers: (i) Which patients to treat?; (ii) Standards for the provision of care; (iii) Pre-treatment considerations; (iv) Which treatment regimens to use?; (v) Stopping rules; and (vi) Management of adverse effects. Finally, we have produced suggested algorithms for the assessment and treatment of these patients.

CONCLUSIONS

These UK Consensus guidelines indicate the current best practice for the use of boceprevir and telaprevir in the management of genotype 1 chronic HCV infection.

Abstract P5-10-20: Breast Cancer Multi Disciplinary Team (MDT)Adjuvant Chemotherapy Decision: Impact of Adjuvant! Online Estimates of 10-Year Risk of Death and Chemotherapy Benefit on the Decision Making Process

Introduction: Breast cancer patients in the UK National Health Service (NHS) are cared for by breast cancer multidisciplinary teams (MDT). The wide range of knowledge and experience available in MDT produce a collective expert opinion on the management strategy for individual patients. Adjuvant! Online is an online computer programme that makes quantitative estimates of the effect of adjuvant chemotherapy (CT) on the 10-year risk of death and relapse. We studied whether the Adjuvant! Online produced numerical estimates would influence the adjuvant CT decision making of a breast cancer MDT.

Methods and Materials: We prospectively monitored a breast cancer MDT for a period of 12 months. Once the MDT had finished discussing a patient and adjuvant therapy decisions were made, Adjuvant! Online produced 10-year risk of breast cancer related death and the reduction of this risk that may be achieved by adjuvant CT were presented to the MDT. Any change to the original MDT recommendations as a result of this information was recorded.

Results: 109 post-operative early breast cancer patients that were suitable for input into Adjuvant! Online discussed in 41 MDT's were included in the study. Adjuvant therapy decisions included chemotherapy (n=56), radiotherapy (n=96) and endocrine therapy (n=89). The numerical estimates from Adjuvant! Online only changed the management of one patient, by showing a marginal (3.8%) survival benefit with CT that made the MDT offer chemotherapy to this patient where the original decision was not to.

Conclusions: Most adjuvant therapy decisions are easy to make without the need for numerical estimates of benefit when the MDT's are staffed by experienced breast cancer clinicians. Regular use of Adjuvant! Online or similar aids may not be necessary during the MDT discussion. These could be used on a selective basis where there is difficulty reaching a consensus.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-20.

Ecological parameters of Lamproglena hoi (Copepoda: Lernaeidae) infection on the Bushveld smallscale yellowfish, Labeobarbus polylepis (Boulenger, 1907)

This study describes the distribution and aspects of the ecology of Lamproglena hoi. Bushveld smallscale yellowfish, Labeobarbus polylepis (Boulenger, 1907) were collected during June 2006 from the Phongolo and Assegaai rivers, March 2005 and October 2006 from the Elands River, and January 2007 and June 2008 from the Komati River in Mpumalanga, South Africa and examined for the presence of parasites. Lamproglena hoi specimens were collected from the gill filaments of the host. Specimens were fixed with warm AFA (alcohol-formaldehyde-acetic acid) and preserved in 70 % ethanol. The identification of parasites took place in the laboratories of the University of Johannesburg. Twenty-five copepods (prevalence 21 %, mean intensity = 4.17, abundance = 0.86) were collected on 29 fish in the Phongolo River and 46 copepods (prevalence 40 %, mean intensity = 3.83, abundance = 1.53) were collected on 30 fish in the Assegaai River. One hundred and sixty eight copepods (prevalence 52 %, mean intensity = 12.92, abundance = 6.72) were collected on 25 fish in 2005, and 527 copepods (prevalence 95 %, mean intensity = 27.74, abundance = 26.35) were collected on 20 fish in the Elands River. One hundred and sixteen copepods (prevalence 75 %, mean intensity = 7.73, abundance = 5.80) were collected on 20 fish in 2007, and 273 copepods (prevalence 63 %, mean intensity = 16.06, abundance = 10.11) were collected on 27 fish in 2008 in the Komati River. Labeobarbus polylepis from these four rivers was found to have a relatively high L. hoi infection. Inseminated L. hoi females (immature) attach to the host in winter and their ovaries become conspicuous (mature). In spring fertilized eggs are stored in egg sacs hanging from the body (gravid), indicating that fertilized eggs start to hatch in spring and continued hatching into summer. Parasites prefer the median part of the second gill arch for attachment. No correlation exists between the number of parasites recorded on the gills and the sizes (total lengths) of yellowfish sampled.

Ecological parameters of Lamproglena hoi (Copepoda: Lernaeidae) infection on the Bushveld smallscale yellowfish, Labeobarbus polylepis (Boulenger, 1907)

This study describes the distribution and aspects of the ecology of Lamproglena hoi. Bushveld small-scale yellowfish, Labeobarbus polylepis (Boulenger, 1907) were collected during June 2006 from the Phongolo and Assegaai rivers, March 2005 and October 2006 from the Elands River, and January 2007 and June 2008 from the Komati River in Mpumalanga, South Africa and examined for the presence of parasites. Lamproglena hoi specimens were collected from the gill filaments of the host. Specimens were fixed with warm AFA (alcohol-formaldehyde-acetic acid) and preserved in 70% ethanol. The identification of parasites took place in the laboratories of the University of Johannesburg. Twenty-five copepods (prevalence 21%, mean intensity = 4.17, abundance = 0.86) were collected on 29 fish in the Phongolo River and 46 copepods (prevalence 40%, mean intensity = 3.83, abundance = 1.53) were collected on 30 fish in the Assegaai River. One hundred and sixty eight copepods (prevalence 52%, mean intensity = 12.92, abundance = 6.72) were collected on 25 fish in 2005, and 527 copepods (prevalence 95%, mean intensity = 27.74, abundance = 26.35) were collected on 20 fish in the Elands River. One hundred and sixteen copepods (prevalence 75%, mean intensity = 7.73, abundance = 5.80) were collected on 20 fish in 2007, and 273 copepods (prevalence 63%, mean intensity = 16.06, abundance = 10.11) were collected on 27 fish in 2008 in the Komati River. Labeobarbus polylepis from these four rivers was found to have a relatively high L. hoi infection. Inseminated L. hoi females (immature) attach to the host in winter and their ovaries become conspicuous (mature). In spring fertilized eggs are stored in egg sacs hanging from the body (gravid), indicating that fertilized eggs start to hatch in spring and continued hatching into summer. Parasites prefer the median part of the second gill arch for attachment. No correlation exists between the number of parasites recorded on the gills and the sizes (total lengths) of yellowfish sampled.

A frame-based representation for a bedside ventilator weaning protocol

We describe the use of a frame-based knowledge representation to construct an adequately-explicit bedside clinical decision support application for ventilator weaning. The application consists of a data entry form, a knowledge base, an inference engine, and a patient database. The knowledge base contains database queries, a data dictionary, and decision frames. A frame consists of a title, a list of findings necessary to make a decision or carry out an action, and a logic or mathematical statement to determine its output. Frames for knowledge representation are advantageous because they can be created, visualized, and conceptualized as self-contained entities that correspond to accepted medical constructs. They facilitate knowledge engineering and provide understandable explanations of protocol outputs for clinicians. Our frames are elements of a hierarchical decision process. In addition to running diagnostic and therapeutic logic, frames can run database queries, make changes to the user interface, and modify computer variables.

Biological risks to food crops fertilized with Ecosan sludge

This paper presents the microbial effects of using Ecosan sludge in agriculture. Sludge from KwaZulu Natal in South Africa having a helminth ova content of around 30 HO/gTS, faecal coliforms of 10(6) CFU/gTS, faecal streptococi of 10(6) CFU/gTS and Salmonella spp. of 10(5) CFU/gTS were applied to soils to grow carrots and spinach at different rates. Results showed that helminth ova content in crops was always greater in leaves than in stems, with a content varying from 2 to 15 HO/gTS for spinach and sludge application rates of sludge of 0-37.5 ton/ha and from 2-8 HO/gTS in carrots crops for sludge application rates varying from 0 to35 ton/ha. Health risks resulting from crop consumption were calculated using the beta-poisson and the single-hit exponential models for Salmonella and helminths eggs, respectively. For Salmonella, no risks were found when consuming carrots for all the sludge rates studied while for spinach, risks were high but results were not deemed conclusive due to the technical methods used to measure bacteria. Concerning helminths, it was found that the morbidity rate will increase by 9% for the higher sludge application rates. To increase regional risks by 1% the egg content in crops needs to be less than 0.2 HO/gTS.

An in vitro study of antimicrobial activity and efficacy of iodine-generating hydrogel dressings

OBJECTIVE

To determine the antimicrobial activity and efficacy of different formulations of novel bioxygenating hydrogel dressings (which deliver both iodine and oxygen into the wound) against various target organisms by means of an in vitro test system that more effectively mimics the conditions encountered when dressings are in contact with wounds.

METHOD

Three bioxygenating hydrogels were tested: Oxyzyme, which releases low levels of iodine into the wound, and Iodozyme 402 and Iodozyme 401, which release higher levels of iodine, with Iodozyme 402 releasing twice the amount of 401. Cellulose filter disks (n = 32) were inoculated with indicator species and placed equidistant from each other as a matrix onto agar test beds. Cut squares of control or test dressings were placed on top of each disk. Kill curves were constructed from determinations of the numbers of survivors (log cfu per disk) over time by removing disk samples at various time points.

RESULTS

Significant differences (p < 0.05) were observed between the controls and test samples. The order of sensitivity for Oxyzyme was Fusobacterium nucleatum, Bacteroides fragilis, Propionibacterium acnes, Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus (MRSA), Candida albicans and Pseudomonas aeruginosa. The order of efficacy of the three hydrogel dressings (Iodozyme 402, followed by Iodozyme 401 and then Oxyzyme) was the same regardless of the target species.

CONCLUSION

The novel hydrogel skin surface wound dressings are broad-spectrum in activity, encompassing antibiotic-resistant organisms, anaerobes and yeasts; their antimicrobial function appears to be rapidly effective.

Using Ecosan sludge for crop production

This paper presents the microbial risks associated with the reuse of Ecosan sludge in agriculture. Sludge from KwaZulu Natal Province in South Africa with a helminth ova content of 30 HO/g TS, faecal coliforms of 10(6) CFU/g TS, faecal streptococci of 10(6) CFU/g TS and Salmonella spp. of 10(5) CFU/g TS was used for this purpose. Applying different rates of sludge to spinach and carrots resulted in an increase in bacterial and helminth ova counts in crops as the quantity of sludge increased. The helminth ova content in crops was always greater in leaves than in stems, with a content varying from 2 to 15 HO/g TS for spinach with sludge application rates of 0-37.5 ton/ha and from 2-8 HO/g TS for carrot crops with sludge application rates varying from 0-35 ton/ha. Nevertheless, viability in crops was 20-25%, reducing the risk of disease. Consequently, the development of an Ecosan sludge revalorisation standard is considered important. Some recommendations are made taking into account the characteristics of the sludge as well as conditions in rural areas.

Nodular regenerative hyperplasia of the liver and coeliac disease: potential role of IgA anticardiolipin antibody

Nodular regenerative hyperplasia (NRH) of the liver is a rare disorder that is often associated with connective tissue disorders, haematological malignancy, or drugs, and is a cause of non-cirrhotic portal hypertension. We describe two cases of NRH in individuals with adult coeliac disease and IgA anticardiolipin antibodies. We discuss the potential impact of this observation on the understanding of the pathogenesis of NRH.

Oesophageal cancer and cachexia: the effect of short-term treatment with thalidomide on weight loss and lean body mass

BACKGROUND

Cachexia is common in patients with advanced cancer and has a direct impact on well-being and mortality.

AIM

To test the hypothesis that thalidomide can promote weight gain and lean body mass in patients with advanced oesophageal cancer.

METHODS

In an open-label study, 11 patients with non-obstructing and inoperable oesophageal cancer were established on an isocaloric diet for 2 weeks, followed by 2 weeks on thalidomide, 200 mg daily. The primary end-points were weight change and lean body mass. Secondary end-points were quality of life and changes in resting energy expenditure.

RESULTS

Ten patients completed the study protocol. The average caloric intake remained the same throughout the study period in all patients. Nine of 10 patients (95% confidence interval, 0.60, 0.98) lost weight on diet alone. The mean weight gain on thalidomide in the following 2 weeks was 1.29 kg (median, 1.25 kg). A similar trend was shown in the lean body mass. Eight of nine patients (95% confidence interval, 0.57, 0.98) initially lost lean body mass on diet alone (missing data in one patient). The mean gain in lean body mass on thalidomide in the following 2 weeks was 1.75 kg (median, 1.33 kg).

CONCLUSIONS

Thalidomide treatment appeared to reverse the loss of weight and lean body mass over the 2-week trial period.

Contraceptive devices and the medical devices directive

The Medical Devices Agency (MDA), an executive agency of the Department of Health, has responsibility for the safety of medical devices within the UK. The MDA is responsible for enforcing the European Medical Devices Directive (MDD) within the UK. Contraceptive devices such as copper-containing IUDs and condoms are regulated by the MDD, and this brief report is an introduction to it.

Production and perception of "verbosity" in younger and older adults

Older adults produced more off-topic speech (OTS) than younger adults during autobiographical interviews in previous studies, a finding attributed to age-related deficits in inhibiting irrelevant information. In this study, older adults produced more OTS than younger adults for autobiographical topics, but not for picture descriptions. A 2nd sample of younger and older participants rated older adults' story quality more positively than that of younger adults, a problematic finding for the inhibitory deficit explanation. Rater age affected ratings of how focused the speech was on the topic, suggesting age differences in criteria for OTS. These findings are consistent with the Pragmatic Change hypothesis, which maintains that older adults adopt communicative goals that emphasize the significance of life experiences rather than conciseness in their personal narratives.

Production and perception of "verbosity" in younger and older adults

Older adults produced more off-topic speech (OTS) than younger adults during autobiographical interviews in previous studies, a finding attributed to age-related deficits in inhibiting irrelevant information. In this study, older adults produced more OTS than younger adults for autobiographical topics, but not for picture descriptions. A 2nd sample of younger and older participants rated older adults' story quality more positively than that of younger adults, a problematic finding for the inhibitory deficit explanation. Rater age affected ratings of how focused the speech was on the topic, suggesting age differences in criteria for OTS. These findings are consistent with the Pragmatic Change hypothesis, which maintains that older adults adopt communicative goals that emphasize the significance of life experiences rather than conciseness in their personal narratives.

Stereological estimates of nuclear number in human ventricular cardiomyocytes before and after birth obtained using physical disectors

Design-based stereology is employed to estimate total numbers of myocyte nuclei and mean myocyte volume per nucleus in ventricles of fetal and early postnatal human hearts. Organs were collected postmortem from subjects varying in age from 16 gestational wk to 40 postnatal wk. Numbers of myocyte nuclei per unit volume of ventricle were estimated using physical disectors (parallel pairs of sections). Absolute numbers were calculated by multiplying nuclear packing densities by ventricular volumes estimated from ventricular mass and tissue density. Volumes per nucleus were obtained via estimates of the combined volumes of all myocytes (or of the myocardium as a whole) and the numbers of myocyte nuclei. The findings showed that numbers of myocyte nuclei increase linearly from 16 wk towards term. They were also consistent with the notion that hyperplasia ceases abruptly at birth or soon afterwards. The net rate of production of myocyte nuclei was about 38 x 10(7)/wk (2.3 million nuclei/h). The total volume of myocytes continued to expand in the same way from 16 wk to at least 35 wk of gestation. Published studies on the incidence of binucleate myocytes during early postnatal growth of the ventricles of rats suggest that the volume of a myocyte doubles prior to nuclear division. Prenatal growth in the human heart is consistent with this mechanism. Myocardial hypertrophy after birth must occur by cellular hypertrophy without karyokinesis.

A stereological method for estimating the total number of ventricular myocyte nuclei in fetal and postnatal hearts

An experimental protocol is presented for obtaining efficient estimates of the total numbers of myocyte nuclei in the ventricles of human hearts from archival collections. Hearts were collected postmortem from fetuses at 31-42 weeks of gestation and infants at 7 days-9 months postnatal age. Ventricles from normal and abnormal subjects were examined. Numbers of myocyte nuclei per unit volume of myocardium were estimated separately for left and right ventricles using a design-based stereological device, the physical disector (parallel pairs of sections). Absolute numbers were calculated by multiplying nuclear packing densities by myocardial volume. The latter was estimated from ventricular mass and the percentage of ventricle occupied by myocardium. The findings, albeit preliminary, suggest that (1) myocyte number may rise during the last trimester of gestation, (2) postnatal ventricular growth is probably hypertrophic and/or interstitial rather than hyperplastic and (3) whilst absolute numbers are greater in the left ventricle, the pattern of growth is similar in both ventricles. Nuclear numbers found in 2 abnormal hearts (1 from a case of sudden infant death) tended to be lower than normal.

From guidelines to decision support in the management of asthma

Asthma is a common chronic disease of the lungs caused by inflammation of the airways affecting 6-7% of the population. Asthma is becoming commoner and there is evidence of under-diagnosis and poor management. Guidelines have been developed aimed at improving quality of care and in reducing social costs of asthma. The paper discusses an approach to implementing guidelines through decision-support system in primary care, based on methods developed in the AIM GAMES-II project. We also describe a prototype system that has been developed and a programme of clinical evaluation.

Roles of insulin resistance and beta-cell dysfunction in the pathogenesis of glucose intolerance in cystic fibrosis

The roles of insulin deficiency and insulin resistance in the pathogenesis of glucose intolerance in cystic fibrosis (CF) were evaluated in eight patients (aged 16.5 +/- 1.9 yr), four with normal glucose tolerance (NGT) and four with impaired glucose tolerance (IGT), and in seven healthy control (CN) subjects. First and second phase insulin secretions were evaluated during a hyperglycemic clamp. Hepatic glucose production (HGP) and insulin-stimulated glucose disposal were measured using [6,6-2H2]glucose and a stepwise hyperinsulinemic-euglycemic clamp. First and second phase insulin levels were significantly lower in both groups of CF patients compared with control values. There was an inverse relationship between glycohemoglobin level and first phase insulin (r = -0.81; P = 0.015) and second phase insulin (r = -0.97; P < 0.001). During the hyperglycemic clamp, the insulin sensitivity index was lower in CF-IGT, but not CF-NGT, compared with control values (6.66 +/- 1.79, 12.82 +/- 1.61, and 13.02 +/- 1.78 mumol/kg.min/pmol.L, respectively; P < 0.05). Basal HGP and fasting plasma glucose were higher in CF vs. CN [24.8 +/- 2.9 vs. 16.9 +/- 1.4 mumol/kg.min (P = 0.036) and 5.8 +/- 0.2 vs. 5.4 +/- 0.1 mmol/L (P = 0.035), respectively]. During the hyperinsulinemic euglycemic clamp, insulin-stimulated glucose disposal was significantly lower in CF-IGT (45.68 +/- 4.87 mumol/kg.min) vs. CF-NGT (78.99 +/- 1.34 mumol/kg.min) and CN (71.74 +/- 6.88 mumol/kg.min). Insulin sensitivity was lower in CF-IGT vs. CF-NGT (7.04 +/- 0.86 and 14.38 +/- 0.84 mumol/kg.min/pmol.L; P < 0.05). We conclude that 1) glycohemoglobin is a strong correlate of insulin deficiency in CF; and 2) glucose intolerance in this group of CF patients occurred as a consequence of concomitant insulin deficiency and insulin resistance.

The relationship of physical fitness to lipid and lipoprotein(a) levels in adolescents with IDDM

OBJECTIVE--Increased physical activity and physical fitness are recommended therapeutic modalities in addition to insulin and diet in the management of children with IDDM. The aim of this study was to assess the fitness levels of adolescents with IDDM compared with healthy control subjects and to evaluate the relationship between physical fitness and metabolic control. RESEARCH DESIGN AND METHODS--We studied 59 patients with IDDM, 28 boys and 31 girls, age 15.6 +/- 2.5 yr, duration of diabetes 7.6 +/- 3.5 yr, HbA1 10.6 +/- 2.1% (mean +/- SD), and compared them with 18 healthy, nondiabetic control subjects, 9 boys and 9 girls, matched for age, BMI, and Tanner stage. Physical fitness was measured by VO2max during progressive bicycle ergometry. HbA1 was used to determine glycemic control. Lipid profile included fasting total cholesterol, HDL, LDL, Lp(a), and TG levels. RESULTS--Patients with IDDM had lower VO2max levels than control subjects (33.7 +/- 7.0 vs. 41.0 +/- 10.4 ml.kg-1.min-1, P = 0.001). Males with IDDM had lower VO2max than male control subjects, but diabetic and control females showed no difference. In IDDM patients, VO2max correlated inversely with HbA1, insulin dose, cholesterol, LDL, TGs, and Lp(a), but did not correlate with HDL, which correlated inversely with BMI. CONCLUSIONS--We conclude that the state of physical fitness is an important correlate of lipid levels and Lp(a) in adolescents with IDDM. We speculate that higher physical fitness levels in adolescents with IDDM may decrease the risk of CVD through modulating lipid levels.